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61 Cards in this Set

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Peripheral Vascular Disease (PVD)
Refers to perfusion disorders related to the blood vessels' ability to deliver O2 and nutrients to and to remove waste products from body tissues
PVD
1. Peripheral Arterial Disease (PAD)
2. Peripheral Venous Disease (PVD)
Risk Factors: PAD
**cigarette smoking
*hyperlipidemia
*HTN
*diabetes mellitus
Others: obesity, hypertriglyceremia, hyperuricemia, family history, sedentary lifestyle, stress, and increased homocysteine
PAD
Describes a wide variety of conditions affecting arteries in the neck, abdomen, and extremities
Leading cause is atherosclerosis -- a gradual thickening of the intima and media of arteries, which leads to progressive narrowing of the vessel lumen. (decreased blood flow)
Arterial PAD
Acute arterial occlusive disease
Chronic arterial occlusive disease
Aneurysm
Arterial Disease/Chronic
Progresses slowly
Prolonged ischemia leads to atrophy of the skin and underlying muscles.
Minor trauma to the feet may result in delayed healing, wound infections, and tissue necrosis, especially in the diabetic patient.
(decreased arterial blood supply)
Manifestations (Chronic)
*Intermittent Claudication--pain that is precipitated by a consistent level of exercise, resolved within 10 minutes or less with rest and is reproducible.
Parasthesia, numbness/tingling toes or feet/burning pain
Loss of both pressure and deep pain sensation
(pain is from lactic acid accumulation)
Manifestations (cont)
Skin -- thin, shiny, taut, dry
Loss of hair on lower legs
Thickened, brittle nails
Decreased or absent pulses
Elevation pallor (legs up = decreased perfusion)
Reactive hyperemia (redness of foot/dependent rubor)
Rest pain (late sign) indication that they need surgery
Arterial Disease/Acute (Acute arterial occlusion)
Occurs suddenly, without warning, abrupt onset
Causes: embolism, thrombosis, or trauma (blood supply is cut off)
*Medical Emergency*
Manifestations (Acute)
Six P's
*Pain
*Pallor
*Pulselessness
*Parathesia
*Paralysis
*Poikilothermia (limb takes on temperature of the environment)
Complications of Arterial Disease
Atrophy (skin & muscle)
Infection
Ischemic Ulcers
Gangrene
Amputation
Ischemic Ulcers (Arterial)
Most common over bony prominences on toes, feet, lower legs, lateral malleolus
No edema
Minimal drainage
Rounded, smooth, punched out appearance
Rarely pruritis or dermatitis
Goals of Therapy
Adequate tissue perfusion
Relief of pain
Increased exercise tolerance
Intact healthy skin and extremities
Treatment: Medical
Risk factor modification
Drug therapy
Exercise therapy
Conservative
Interventional Radiology
Risk Factor Modification
Smoking cessation
Aggressive treatment of hyperlipidemia
Ideal body weight achieved and maintained
Tight control of HTN and DM
Drug Therapy (Chronic)
Antiplatelet Agents -- ASA, Plavix, Ticlid
Drugs for intermittent claudication
Trental - increases erythrocyte flexibility and decreases blood viscosity. (blood flows better)
Pletal (newest) - inhibits platelet aggregation and increases vasodilation
*Need to treat chronic afib with long term anticoagulation (Coumadin)
Drug Therapy (Acute)
IV heparin
Intraarterial infusion of a thrombolytic agent (TPA - Tissue Plasminogen Activator)
Exercise Therapy/Chronic
Formal exercise training program
Walking - walk daily until the point of pain
*Improves oxygen extraction in the legs and skeletal muscle metabolism.*
Conservative
Protect extremity from trauma-avoid chemicals/heat, footwear-soft/roomy/protective
Decrease vasospasm - avoid heat/cold
Prevent and control infection -careful inspection, cleansing, and lubrication
Maximize arterial perfusion-heels kept free of pressure
Feet in the dependent position
Feet in arterial position=dependent position
Interventional Radiology
Percutaneous Transluminal Balloon Angioplasty - through femoral artery, balloon inflated, cracks intimal shell and stretches media
Atherectomy - laser tipped, burns plaque before dilation
Intravascular Stents - metallic devices placed in the artery after angioplasty
**Post procedure - monitor site for bleeding, monitor pulses, bed rest (Head flat for 6 hours - monitor peripheral pulses)
Treatment: Surgical
Peripheral Arterial Bypass Graft - vein or synthetic graft bypasses/carries blood around lesion
Endarterectomy-opening artery and removing obstruction (plaque)
Patch Graft Angioplasty - open artery, remove plaque, sew a patch to opening to widen the lumen
Amputation (beyond surgical repair = amputation)
Figure 37-6
Implementation: Post-op care for Arterial Bypass
*Monitor extremity closely-CSM, pain, pulses
*loss of pulses, numbness & tingling (embolism through bypass graft)
-notify MD immediately*
Keep heels free from pressure
Avoid knee flexion
OOB
Home Care - manage risk factors, inspect legs, feet daily for temp & color changes, clean all wounds, comfortable/round toe shoes/insoles
Teaching Plan 37-5 (p.296 Lewis)
Venous PVD
Chronic Venous Insufficiency
Venous Ulcers
Chronic Venous Insufficiency (CVI)
CVI - A condition where valves in extremities are unable to close, allowing blood to flow backward into dilated veins (retrograde backflow of blood)
Causes: CVI
Vein incompetence, vein obstruction, congenital venous malformation, AV fistula, and calf muscle failure
Patho/Manifestations (CVI)
Incompetent valves in deep vein
Increased pressure leads to serous fluid and RBC's leaking from capillaries and venules into the tissue which leads to edema
Enzymes in the tissue breakdown RBC's which leads to the release of hemosiderin which causes brownish skin discoloration
Varicose veins may be visible
Patho/Manifestations (CVI)
Skin and SC tissue around the ankle is replaced with fibrous tissue, this leads to thick, hardened, contracted skin
Pain - aching pain after standing for a long time, relieved by walking or elevation
-pressure or cramp-like sensation
-leg cramps at night
Venous Ulcers
Leg ulcers are associated with chronic venous insufficiency and accumulation of deoxygenated blood
Results from damage to the integrity of skin and tissues
Manifestations/Venous Ulcers
*Classically located above the medial malleolus
Wound margins irregularly shaped
Tissue is a ruddy color
Partial thickness
Extensive drainage
Painful
Very itchy/dry around
Complications
Wound infection
Cellulitis (surrounding tissue becomes infected)
Secondary lymph edema
Thrombophlebitis
Amputation
Rupture (varicose veins)
Venous Disease: Treatment
Medical:
Prevention
Compression
Moist Dressing
Optimize Nutrition
Radiant Heat Bandage (alternate therapy)
Sclerotherapy (varicose veins)
Treatment: Prevention
Avoid trauma to limbs
Daily moisturizing-decrease itching, prevent cracking
Assess S&S of infection
Avoid sitting/standing with feet dependent of rlong periods/avoid leg crossing
Elevation-above level of heart
Daily walking (once ulcer has healed)-followed by elevation
Maintain ideal body weight
Avoid constrictive clothing
Treatment: Compression
**Most useful treatment for venous stasis ulcers, leads to decreased venous stasis and edema
Variety of options-elastic wraps, unna boot, custom fitted compression stockings, velcro wrap, sequential pneumatic compression devices
Need to put on before client gets OOB
Need to assess arterial status --ABI >0.8 Can't use with active cellulitis
Arterial & Venous Disease together = NO COMPRESSION
Treatment: Dressings
*Needs to be used in conjunction with extrinsic compression
Moist more effective than dry dressings for healing
Moist transparent film (tegaderm)
Hydrocolloids (duoderm)
May need aquacel to absorb
Treatment: Nutrition
A balanced diet with adequate protein, calories, and nutrients
Nutrients most important for healing include: protein, vitamins A and C, and zinc
Patients with DM-maintain normal glucose
Overweight with CVI-weight reduction diet
*If active venous ulcers-no weight reduction
Treatment: Sclerotherapy
Direct IV injection of sclerosing agent (sodium tetradecy) into superficial varicose veings - causes inflammation, vein thrombosis, disappear
**Post procedure
-Elastic wrap for 24-72 hours
-Compression stockings for prevention
Laser therapy option for superficial varicosities
Treatment: Surgical
Ligation-(varicose)-of entire vein and dissection and removal of its' incompetent tributaries
Split thickness skin graft-ulcer is debrided, varicosities removed, veins ligated before tissue from a donor site is applied
Bioengineered skin
Treatment: Surgical/Post Op
Monitor CSM, edema, temperature
Check pedal pulses
*Bruising/discoloration is normal
Elevate legs 15 degrees to prevent venous stasis & edema
Compression stockings - remove & reapply every 8 hrs
Assessment: Physiological Integrity
Health history
Pain
Family history
Medications
Previous vascular surgery
Presence of risk factors
Assessment (cont)
B/P
Inspection: extremity
Palpation
-pulses
-Temperature
Auscultation: bruit (femoral)
Assessment: Diagnostic Studies
Doppler ultrasound
Ankel-brachial index
Duplex imaging
Angiography
Magnetic resonance angiography
Doppler Ultrasound
Measures blood flow velocity, direction of flow
Blood pressures measured in thigh, below knee and at ankle
Useful in obtaining pulses in lower extremities when they are not palpable
Ankle-brachial Index
Obtained by dividing ankle SBP by highest brachial SBP
Normal = 1.0
Abnormal <1.0
*Lower the ABI the worse the PAD
*ABI - useful in monitoring lower extremity bypass graft patency
Duplex Imaging
Uses a doppler to map blood flow throughout the entire region of an artery
Gives anatomic and physiologic data about vessels
Angiography (Invasive)
Further refines data obtained in duplex imaging
Useful when intervention is indicated
Involves the use of dye - toxic to kidneys
iodine allergy
**done through femoral artery-monitor site for bleeding, pedal pulses, CSM, bed rest
Magnetic Resonance Angiography (MRA)
Angiogram done by MRI, using dye that is not toxic to the kidneys
**being used more**
Assessment: Safe Effective Care Environment
Knowledge of ways to prevent LE (lower extremity) injury
Knowledge of care of LE injuries
Assessment: Psychosocial Integrity
Body image changes related to skin impairment
Role function changes related to activity intolerance or skin impairment
How client copes with the disease process and necessary life style modifications
Analysis/Diagnosis
Acute pain
Impaired skin integrity
Ineffective tissue perfusion
Disturbed body image
Ineffective role performance
Summary/Outcomes
Blood flow to and/or from affected extremity will improve
Client will adopt health seeking behaviors to minimize progression of PVD
As much limb as possible will be preserved
Arterial or Venous?????
Parasthesia
Arterial
Arterial or Venous????
Heavy ulcer drainage
Venous
Arterial or Venous????
Edema around the ankles
Venous
Arterial or Venous????
Gangrene over bony prominences, toes, or feet
Arterial
Arterial or Venous????
Decreased peripheral pulses
Arterial
Arterial or Venous????
Brown pigmentation of the legs
Venous
Arterial or Venous????
Thickened brittle nails
Arterial (decreased perfusion)
Arterial or Venous????
Ulceration around the medial malleolus
Venous
Arterial or Venous????
Pallor on elevation of the legs
Arterial
Arterial or Venous????
Dull ache in calf or thigh
Venous
Arterial or Venous????
Pruritis
Venous